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/ Faculty of Public Health, Mahidol UniversityAPPLICATION FOR
MASTER OF PUBLIC HEALTH (MPH)
INTERNATIONAL PROGRAM
Academic Year ______ / Please attach
PHOTO
here
Please type or print clearly
1. Name (Last, First, Middle) …………………………………………………………………………………………
2. Place of Birth (City/Country) ………………………………………………………………………………………
3. Citizenship (Country) ………………………………………………………………………………………………
4. Date of Birth …………/…………./…………… (date/month/year)
5. Current Mailing Address
Home
Street ……………………………………………………………………………………………………….
City …………………………………………………………………………………………………………
Country …………………………………………………………………………………………………….
Tel. …………………………… Fax ………………………..… E mail ……………………………..
Work
Street ………………………………………………………………………………………………………
City …………………………………………………………………………………………………………
Country ……………………………………………………………………………………………………
Tel. ……………………….…… Fax …….…………………… E mail …………………………….
6. Permanent Address
Street ………………………………………………………………………………………………………
City …………………………………………………………………………………………………………
Country …………………………………………………………………………………………………….
Tel. ……….…………………… Fax …….…………………… E mail ……………………………..
7. Sex [ ] Female [ ] Male
8. Marital Status [ ] Single [ ] Married
9. Please select two desired areas of concentration (1st choice = 1, and 2nd choice = 2)
[ ] Primary Health Care [ ] Health Promotion [ ] Public Health Technology
[ ] Dental Public Health [ ] Urban Health [ ] Human Health Development
[ ] Community Health Services Development [ ] Reproductive Health
(Please note: A minimum of seven international students is required for each area to be offered)
10. College/University level education (beginning with most recent) :
Name and address of instituttion / Location (Country) / From
(mo/yr) / To
(mo/yr) / Degree obtained / Major
11. Special training course attended :
Title of Course / Location (Country) / From (mo/yr) / To (mo/yr)
12. Work Experience (beginning with most recent) :
Position / Organization/Agency / From (mo/yr) / To (mo/yr)
13. Indicate level of English Proficiency :
Poor / Fair / Good / Excellent
Reading
Writing
Speaking
14. English Proficiency Test :
[ ] TOEFL Score : ……… Date of Test ….….../…....……./…..(month/day/year)
[ ] Other (specify) ……………… Score : ……… Date of Test …….../……..……/……(month/day/year)
15. English language was used as a teaching medium during undergraduate study. [ ] Yes [ ] No
16. Computer Use
- How many hours per week do you use a computer?
- How many times per week do you have access to Internet?
- Indicate how you use the computer to search for information. Give the percent for each category below.
[ %] Have others (Librarian, staff) find information for use
[ %] Search general search engines (e.g. Yahoo, MSU, America online) for information
[ %] Use specialized search engines (e.g. Medline) to find information
17. Source of financial support :
[ ] Private
[ ] Sponsor (specify) Sponsor’s Name …………………………………………………………………….…
Duration and amount per year ………………………………………………………..
I hereby certify that the information given on this application is complete and correct to the best ofmy
knowledge. I understand that concealment of such information may result in the rejection of my application
or disciplinary action if discovered after enrollment.
Applicant’s Signature ………………………………………… Date ………./……..……../……….(month/day/year)
Referees : 1. Name ………………………………………. Position/Title ……………………………………………
Organization ………………………………. Tel/Fax ………………………… email ………………..
2. Name ………………………………………. Position/Title ……………………………………………
Organization ………………………………. Tel/Fax ………………………… email ………………..
Accompanying Documents Required :
1. 35 US$ Application Fee (non-refundable).
2. One official transcript from each academic institution attended.
3. A recent medical examination report.
4. One-page statement describing in your own words your long-range education and professional goal
5. Two letters of reference (which are mailed directly to this office by the referee).
6. English Proficiency Test Certificate (TOEFL or equivalent) or a letter of confirmation of using English as a
teaching medium during undergraduate study.
7. If application has a founding agency, a letter to certify that he/she gets scholarship is needed.
8. If an applicant is self-sponsored, bank statement with the fixed amount of 8,000 USD is needed.
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CONFIDENTIAL
MAHIDOL UNIVERSITY FACULTY OF PUBLIC HEALTH
APPLICATION RECOMMENDATION FORM
Name of Applicant ......
Program of Study......
TO THE RECOMMENDER:The Faculty of Public Health would appreciate your candid evaluation of the
above-named applicant. Please include your personalimpressions
of the candidate’s professional skill, past academic performance, previous
work experience, personality andmotivation.
Please mail this recommendation form to:Dean, Faculty of Public Health, Mahidol University
Rajvithi Road, Rajthewee, Bangkok 10400, THAILAND
Recommender’s signature ……………………………………..Date......
Name (type or print)......
Title / Position......
Institution......
Address......
......